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Dance Registration Form
Dance Studio Registration for Image Dance Company & Academy. Please fill out as completely as possible.
Email address *
*
First and last name
Your answer
Student's Date of Birth *
MM
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DD
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Parent's/Guarian's Name *
Your answer
Relationship *
Your answer
Parent's/Guardian's Phone Mobile # *
Your answer
Parent's Guardian's Home/Work # *
Please specify if home or work.
Your answer
Additional Parent/Guardian name *
Your answer
Additional Parent/Guardian contact # or email *
please specify if mobile/work/or home #
Your answer
How did you hear about Image Dance Co. & Academy
Which classes are you interested in? *
Required
Waiver & Liability Release *
I release Michelle Angulo-Pacheco and Image Dance Company & Academy, any of its representatives ofvolunteers , management or instructors, HEB Grocery Company, PC, owner of premises, HEB Shopping Center Development, from any personal injuries to myself, my children (students or non-students) of the studio, or to any person within the premises of Perrin Oaks Shopping Center or to 4105 Avenida Prima, San Antonio, TX 78217. * I also give permission to Image Dance Co. & Academy and Michelle Angulo-Pacheco, director, to utilize pictures taken at classes and/or performances for advertising and promotional purposes with no expectations of monetaryor credit reimbursement. I understand that these shall be in good taste AND are for the promotional purposes ofthe dance studio and its performance and community activities with the clients and students.
Date
MM
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DD
/
YYYY
Registration Fee *
Please check and follow link to pay registration fee.
Policy Book *
Please check both. Link leads to the policy book
A copy of your responses will be emailed to the address you provided.
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